Making the Safe Choice the Easy Choice: How Healthcare Leaders Are Advancing Patient Safety

This article builds on insights shared during the “Hardwiring for Patient Safety” session at Breakthroughs 26, Premier’s annual conference exclusively for Premier members

When a patient safety concern emerges, education is often one of the first steps healthcare organizations take. Teams review policies, reinforce expectations and make sure clinicians understand the practices designed to keep patients safe.

That work matters. But knowing what to do does not guarantee that it will happen consistently.

Healthcare is complex. Clinicians work within established processes while balancing competing priorities, changing patient needs and limited resources. A safety practice that depends heavily on someone remembering an extra step can become difficult to sustain, even when staff understand why it matters.

For healthcare leaders, the challenge is figuring out how to move from awareness to reliability. That often requires looking closely at how work happens and designing processes that support safer practices as part of everyday care.

Start With the Workflow

A policy may clearly define what should happen, but the people carrying it out can reveal whether the process works in practice.

St. Luke’s University Health Network saw that firsthand while standardizing suicide screening and observation practices across its network. The health system revised its policies, adopted a universal screening approach and provided mandatory education for nursing staff. As the work progressed, however, documentation in the emergency department (ED) emerged as an opportunity for improvement.

Linda Machado, Director of Quality and Patient Safety for the Behavioral Health Service Line at St. Luke’s, met with frontline ED staff to understand how they worked. That changed her perspective on the documentation process.

“After I did that, it made sense to me why there was so much confusion,” said Machado. “We actually revised the ED’s documentation within our electronic medical record to help it flow better with the actual workflow of the policy.”

The experience points to an important consideration for patient safety work. When people struggle to follow a process, more education may not address the underlying problem. Leaders may need to look at the process itself and ask whether it fits naturally into the way care is delivered.

Make the Desired Practice Easier to Follow

Carissa Fegley, Director of Patient Care Services at St. Luke’s Sacred Heart Campus, took a similar approach when her team set out to improve communication with patients about their medications.

The project focused on a medical-surgical unit where communication about medications remained an opportunity even as other patient experience measures improved. The unit finished fiscal year 2024 in the 28th percentile for medication communication.

Fegley’s team developed a resource that focused on commonly used medication types and classifications relevant to the hospital’s patient population. Rather than creating a separate process for nurses to remember, they added the resource to an admission packet staff already used.

“If we wanted to make new process changes and put them in effect, we had to make them easy,” said Fegley. “We really tried to make this kind of a no-think strategy for them by taking the tools that we created for this process and implementing them into already existing workflows.”

The team also decided medication conversations should be part of the process consistently, rather than only when a patient started a new medication. Audits were incorporated into existing leadership rounding so staff knew the practice would continue to be monitored.

By fiscal year 2025, the unit had reached the 99th percentile for communication about medications and remained at the 92nd percentile in fiscal year 2026.

The results show what can happen when improvement work considers the demands of daily care. Adding another task may create another opportunity for variation. Building the practice into something staff already do can make consistency more achievable.

Bring Frontline Staff Into the Design Process

Frontline engagement can also uncover gaps that aren’t obvious in a project plan or performance dashboard.

As Fegley’s team developed its medication communication work, leaders brought the challenge to nurses and asked them to help shape the solution. Staff meetings and huddles became opportunities to discuss what was working, what wasn’t and what needed to change.

One suggestion proved particularly important. Frontline staff pointed out that the new medication education resource wasn’t available in Spanish, despite the hospital serving a significant Spanish-speaking population. The team had the document translated and incorporated interpreter services into the education process.

“We knew what the end result needed to be, but we really wanted to have the staff that do the job every single day have input in it,” said Fegley. “Some of our best suggestions for this process came from the staff.”

Frontline involvement can do more than build support for a change. It gives leaders access to the practical knowledge of the people who will use the process every day.

Expect the Process to Evolve

Even thoughtfully designed interventions may need to change once they encounter the realities of clinical care.

At Riverside Health, Mary Del Sol, Medical-Surgical Nurse Manager and Inpatient Wound Care Coordinator, has been working to reduce pressure injuries. The organization embedded alerts into its medical record so that when patients meet certain Braden score criteria, staff are prompted to order prevention interventions, including turning, heel boots, wedges and a turning and positioning system. Riverside has cut its pressure injury prevalence rate roughly in half through its broader improvement work.

One part of the process has remained particularly challenging: completing and documenting patient turns every two hours.

The electronic workflow included reminders, but reminders alone didn’t consistently produce the intended result. Riverside explored turn buddies using existing staff and later additional team members dedicated to turning. Staffing demands made those approaches difficult to sustain consistently. The organization is now exploring technological solutions, including virtual nursing and tools that could support turning and documentation.

“As much as we wish we could predict every moment on a shift, that’s just not the reality,” said Del Sol. “We have a couple of things in the background to make sure we pick the solution that’s right for us that keeps patients safe.”

Her experience is a reminder that hardwiring is an ongoing process. An alert in the electronic health record may solve one barrier while staffing or workflow exposes another. Monitoring how an intervention performs in practice gives teams the opportunity to adjust rather than assume the original solution should work indefinitely.

Use Measurement to Keep Improvement Moving

Measurement is especially valuable when it helps teams understand what is happening and decide what to do next.

At St. Luke’s, Machado initially relied on manual audits to monitor suicide screening and observation practices across the network. The health system later worked with its data analytics team to create a near-real-time Tableau report that allows leaders to review patient risk levels and whether patients received one-to-one or virtual observation. Machado reviews the information monthly and shares identified opportunities with individual departments, along with quarterly reporting to nursing leadership.

The changes also helped St. Luke’s use observation resources differently. Virtual patient observation became an option for patients identified as low or moderate risk, while in-person one-to-one observation or ligature free secure holds remained the intervention for high-risk patients. Together, the work generated nearly $3 million in savings for the health system.

Fegley’s team found value in looking beyond quantitative performance. Alongside patient experience scores, leaders reviewed individual surveys and patient comments and shared feedback with staff. As the project progressed, patients began specifically recognizing nurses for conversations about their medications.

Seeing those comments helped connect a performance measure to the patient experience behind it. The numbers showed whether performance was moving. Patient feedback helped staff understand what that improvement meant for the people receiving care.

Build Safety into the Way Work Gets Done

Education will always have a place in patient safety improvement. Policies need to be understood, new practices need to be taught and expectations need to be clear. The work becomes harder when education is expected to carry the full weight of sustained change.

The experiences at St. Luke’s University Health Network and Riverside Health show the value of looking deeper. How well does a policy fit the actual workflow? Where are staff still relying on memory? What are frontline teams seeing that isn’t apparent in the data? And when a process doesn’t work as expected, what needs to change?

Patient safety improvement continues long after training is complete. It takes ongoing attention to the systems surrounding the people providing care, along with a willingness to learn from what happens once a new process reaches the bedside.

The goal is to give clinicians more than instructions for doing the right thing. It is to build working environments that help them do it consistently.

For more:

• Explore more insights on quality and patient safety and learn how healthcare leaders are approaching some of today’s most pressing clinical challenges.